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Deformable image registration is a valuable tool, especially for contouring difficult structures like the brachial plexus. This was corrected withminor modifications for each individual to ensure consistency. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

The underlying mechanismis thought to be due to demyelination leading to axon loss [ 9 ]. As improvements in surgical and radiation techniques and chemotherapy regimens lead to longer survival for patients with lung cancer, the need to monitor toxicity and adapt our practice accordingly becomes ever more imperative.

The median radiation dose to the brachial plexus was 70 Gy range Dose-volume histogram data showing the median radiation dose of 10 patients manually contoured forming the training set dotted line compared to the automatically generate plexus contours using deformable image registration, prior to modification.


For these reasons, estimates of smaller point doses may not have been accurate 5611 to predict the development of plexopathy. As the recommended radiation dose for non-small cell lung cancer NSCLC increases, meeting dose constraints for critical structures like the brachial plexus becomes increasingly challenging, particularly for tumors in the superior sulcus.

There were minimal differences in DVHs between the auto-segmented contours and 51661 modified contours. National Center for Biotechnology InformationU. Also, changes in arm position can affect the visibility of the brachial plexus and can contribute to inaccuracies in deformable image registration. The multi-atlas segmentation technique we used has the potential to reduce inter-subject, inter-observer, or even intra-observer variability in contouring the brachial plexus.


Journal of Clinical Oncology. Conclusions For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy. For lung cancers near the apical region, brachial plexopathy is a major concern for high-dose radiation therapy.

The Pinnacle planning system was used to calculate the dose to the brachial dvn using the original treatment plan. Minor clinical symptoms with no medical intervention required were considered grade 1; moderate symptoms requiring pain medication with good response, grade 2; and severe symptoms, treated with multiple pain medications, including neuropathic drugs or steroid injections, with some or no improvement in symptoms, grade 3.

In this study we found that plexopathy before treatment was also associated with greater risk of toxicity after treatment. Deformable Image Registration To save time and improve the consistency of contouring, we applied a new multi-atlas segmentation method to automatically delineate brachial plexus contours as follows.

Brachial plexopathy can present with a wide range of symptoms, often irreversibly, including numbness, pain, parasthesias, and motor impairment [ 8 ].

Complication without a cure. We developed a computer-assisted image segmentation method which allowed us to rapidly and consistently contour the brachial plexus and establish the dose limits to minimize the risk of brachial plexopathy. Initial results of the phase II trial RTOG to evaluate the feasibility of dose escalation to 74 Gy with concurrent chemotherapy for unresectable NSCLC were encouraging; the median overall survival time, 24 months, compares favorably 5611 that produced by the lower Gy dose used in RTOG [ 6 ].

Dvn two curves were nearly superimposable. Dose escalation introduces challenges with regard to meeting dose constraints for proximal critical structures such as the brachial plexus. The Mann-Whitney two-sample statistic or Wilcoxon rank-sum test was used to test the distribution of continuous variables according to plexopathy status. Significant effect of adjuvant chemotherapy on survival in locally advanced non-small-cell lung carcinoma.

Of these, 5 patients Tolerance of normal tissue to therapeutic irradiation.

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Support Center Support Center. Our study had several limitations. The maximum doses to 0. Unfortunately, these are the very patient likely to justify dose escalation as they often have gross tumor pushing on the nerve, and perhaps the risk is justified because recurrent tumors will also result in further morbidity.


Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer–a review.

Author manuscript; available in PMC Sep The median time to symptom onset was 6. Balancing the benefit of local control with the risk of considerable toxicity is a particular challenge for tumorsof the superior sulcus or tumors with supraclavicular adenopathy.

This may prove to be problematic for complying with dose constraints to structures like the brachial plexus. Lung cancer is the leading cause of cancer-related death worldwide, with approximately 1.

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We also evaluated the contribution of other factors, such as having plexopathy before radiation, receipt of concurrent chemotherapy, and receipt of proton versus photon therapy, to the risk dvj developing brachial plexopathy. Proc Am Soc Clin Oncol.

Additional inclusion criteria were having at least 4 months of follow-up and having had either photon or proton therapy with 3D conformal or intensity-modulated radiation treatment planning, with or without concurrent chemotherapy. Our findings here, focusing specifically on patients treated for lung cancer, indicate that the median dose to the brachial plexus should be kept below 69 Gy, and the maximum dose to 2 cm 3 below 75 Gy,for patients with NSCLC. III, IV and recurrent.

The planned tumor volume PTV received 74 Gy. Using the clavicle and first rib as landmarks [ 11 ], we used bony anatomy and dvn subclavian bundle to draw the plexus distally.

Most studies since have recommended the maximum dose be 51161 under 66 Gy.